First Name - Inland Marine
|Individual Applicant Information | Primary Applicant | Co-applicant |Date: |
|First Name |Middle Name |Last Name |Suffix |
| | | | |
|Social Security Number |Birth Date |Driver’s License No. |State | Unmarried |
| | | | |Married |
| | | | |Separated |
| | | | | |
|Home (check preferred contact) |Work Phone |Cell Phone |Email Address |
|( ) – |( ) – |( ) – | |
| Own Rent|Street Address (No P.O. Boxes) |Apt. |
|Family |State | |
| | | |
|How Long? |City |State |Zip |County |
| yrs | | | | |
|Previous Residence Address (if less than 5 yrs at current) |City |State |Zip Code |How Long? |
| | | | | yrs |
|Employer |Title |Monthly Employment Income |
| | |Gross: |Net: |
|Street Address |City |State |Zip Code |How Long? |
| | | | | yrs |
|Previous Employer (if less than 5 yrs at current) |City |State |Zip Code |How Long? |
| | | | | yrs |
|Nearest Relative (not living with you) |Relationship |Street Address |City |State |Home Phone |
| | | | | | |
|Checking Acct. Bank Name |Savings Acct. Bank Name |Last boat financed with: |Monthly Payment |
| | | | |
|Mortgage / Landlord Name |Monthly Payment |Sources of Other Income (see * below) |Monthly Amount |
| | | | |
|Have you declared bankruptcy in the last 10 years? | Yes No |* Alimony, child support or separate maintenance income need not be revealed if you |
| | |do not wish to have it considered as a basis for repaying this obligation. |
|Have you ever had any property repossessed? | Yes No | |
|Authorization and Certification |Signature |
|The undersigned: (1) Makes all of the above representations, which are certified correct, for the purpose of securing |X |
|credit; (2) Authorizes Inland Marine and any prospective lender to gather whatever credit information and employment | |
|history is considers necessary and obtain credit reports periodically; (3) Authorizes Inland Marine to use and share | |
|information with other entities that are related to it by common ownership or control; (4) Understands that Inland | |
|Marine will retain this application whether or not it is approved, and that it is the applicant’s responsibility to | |
|notify the creditor of any changes of name, address, or employment; and, (5) Authorizes Inland Marine to share this | |
|information with an Marine Insurance Agency if an insurance quote is requested below. | |
|Boat Information (complete on “primary application”) |
|Boat |Year |Make |Model |Length |Hull ID |
| New | | | | | |
|Used | | | | | |
|Motor(s) |Year |Make |Model |HP |Type |
| New | | | | | Inboard I/O Outboard |
|Used | | | | | |
|Fuel |Serial Number Motor 1 |Serial Number Motor 2 |Seller |
| Gas | | | Private Broker Dealer |
|Diesel | | | |
| | | |Name(s) |
|Sale |Registration and Titling | |
|Agreed Sale Price |$ |Boat will be registered in the state of: | |
| | | |Address |
|Sales Tax (+) |$ | | |
| | |Current registration or Documentation #: | |
|Title/Registration Fees (+) |$ | |City, State, Zip |
|SUB-TOTAL = |$ | | |
| | |Is there a Lien? Yes No if yes, then: | |
|Down Payment (-) |$ |Amount |$ |Day Phone |
| | |Bank | | |
|AMOUNT REQUESTED |$ |Acct # | |Evening Phone |
| | |Phone | | |
|Please provide a no obligation Insurance Quote: | Yes No | | |
INLAND MARINE 1600 W. 10TH ST ANTIOCH, CA 94509 PH:925-757-1714 FAX 925-757-1729 WWW.INLAND-
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